"*" indicates required fields Time* Hours : Minutes AM PM AM/PM Date* MM slash DD slash YYYY Client Name* First Last Pet Name*Pet Age*1. What concerns you about your pet today (please be specific)?*2. How long has this problem been going on? Is this a recheck?*3. Are there any other problems?* Yes No 4. Past pertinent history? (Surgeries/diagnosis? )*5. General appearance/attitude?*6. Any behavioral problems?* Yes No If yes, explain:*7. Any allergies?* Yes No If yes, explain:*8. Any history of seizures?* Yes No 9. Is your pet:* Outdoor Indoor Both 10. Does your pet have any access or exposure to open space? Tick Exposure?* Yes No 11. Any potential exposure to toxins? (insecticides, poisons, antifreeze, etc)?* Yes No If yes, what?*12. Has your pet had any of the following?:Vomiting* Yes No If yes, How long?*Diarrhea* Yes No If yes, How long?*Coughing* Yes No If yes, How long?*Sneezing* Yes No If yes, How long?*13a. Is your pet: Eating Normally?* Yes No 13b. Is your pet: Drinking Normally?* Yes No 13c. Is your pet: Urinating Normally?* Yes No 13d. Is your pet: Bowel Movements Normal?* Yes No 14. What is your pet's diet:*BrandHow much?Grain free? (Y/N) Add Remove15. Is your pet taking any medications?* Yes No If yes, what medication/dosage? (please be specific so we can verify this with what is in your patients medical record)*MedicationDosage Add Remove16. Is your pet on consistent flea control?* Yes No What brand? (please be specific so we can verify this with what is in your patients medical record)*17. Is your pet microchipped?* Yes No 18. Is your pet spayed/neutered?* Yes No 19. Is your pet current with their rabies vaccination?* Yes No 19a. Other Vaccination?* Yes No 20. Any history of vaccine reactions?* Yes No 21. Has your pet had a fecal analysis in the last 6 months?* Yes No 22. Is your pet on consistent heartworm prevention?* Yes No What brand? (please be specific so we can verify this with what is in your patients medical record)*23. Are there any other pets at home?* Yes No How many?*DogsCatsOthers24. Do you have pet insurance?* Yes No If yes, what insurance provider do you have? (If none, put n/a)*Do you need any written prescriptions or any medication filled at the time of the appointment (this includes prescription food or flea/tick prevention)?I authorize Martinez Animal Hospital to charge up to this amount in case I am unavailable for contact*In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked.PrimaryAlternateIF YOU ARE 10+ MINUTES LATE TO YOUR APPOINTMENT, IT IS UP TO OUR DISCRETION IF WE CAN STILL TAKE YOUR APPOINTMENT. A $10 LATE ARRIVAL FEE WILL APPLY .*I agree (Initial here)WE REQUIRE 24 HOUR NOTICE FOR RESCHEDULING AND CANCELING APPOINTMENTS. IF YOU DO NOT PROVIDE US 24 HOUR NOTICE, YOU WILL BE CHARGED A MISSED APPOINTMENT FEE. BY CHECKING THIS BOX, YOU UNDERSTAND THAT IF YOU DO NOT GIVE US APPROPRIATE CANCELLATION NOTICE, YOU MAY BE ASKED TO PRE-PAY FOR YOUR NEXT APPOINTMENT.*I agree (Initial here)Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
